In my last post, I looked at cognitive scripts and the concept of stuckness. In this post, I’ll look more closely at how this concept is particularly relevant to youth with a history of trauma, abuse or neglect.
More than eight million American children suffer from serious, diagnosable trauma-related mental health problems (Perry & Szalavitz, p. 3); adolescents with impaired stress response systems resulting from long-term traumatic exposure are most likely to develop ongoing, significant drug problems (Perry & Szalavitz, p. 189) and other mental health problems (Perry & Szalavitz, p. 246). Additionally, surveys of adolescents receiving treatment for substance abuse found that more that 70% reported a history of trauma exposure, while other studies have found that 57% of adolescents in treatment come from homes where violence occurred frequently, and 40% reported being physically abused (Lawson & Lawson, p.176).
These statistics clearly show that there is a strong connection between substance abuse and a history of traumatic stress. In addition to substance abuse, adolescents with such histories often turn to a number of potentially destructive behaviors in an effort to avoid or defuse the intense negative emotions that accompany this traumatic stress. These behaviors often include engaging in risky sexual behaviors, self-mutilation, bingeing and purging, and suicidal behaviors. This serve to further traumatize these youth, reinforcing their already maladaptive cognitive scripts. Understanding the connection between substance abuse, trauma, and this cascade of chaos is important if we wish to assist our clients in moving forward.
Trauma in Early Childhood
As I’ve written before, nearly all my clients have predictable cognitive scripts. This is especially true with trauma survivors. When faced with even small life challenges, these youth predictably act up, shut down, or use. Hebb wrote, “…any two cells or systems of cells that are repeatedly active at the same time will tend to become ‘associated,’ so that activity in one facilitates activity in the other” (qtd. in Siegel, p. 26). In other words, “Experience, gene expression, mental activity, behavior, and continued interactions with the environment are tightly linked in a transactional set of processes” (Siegel, p. 19).
These processes begin at birth. Repeated similar experiences lead the mind to make generalized representations that form the basis of mental models used to “interpret present experiences as well as anticipate future ones” (Siegel, p. 29-30), suggesting that an individual is most likely to respond to life events in standard, predictable and learned ways.
Perry and Szalavitz stated that repeated activation of the stress response system cleads to “a cascade of altered receptors, sensitivity, and dysfunction” (p. 24). In other words, over-activation of a system can result in becoming over-reactive, or they as described it “sensitized” (Perry & Szalavitz, p. 36). A common causation of this sensitized state is childhood neglect, abuse and other early childhood trauma. In these cases, that trauma becomes part of the individual's mental models. In other words, traumatic stress leads to the expectation of more traumatic stress, which becomes a self-fulfilling prophecy. After all, expecting stress is stressful all by itself.
When individuals exposed to childhood trauma move into adolescence, they face a new cascade of problems. These can include a higher incidence of mental health disorders, school-related concerns, placement in separate classes, and increased association with peers who exhibit similar maladaptive issues. This cascade of problems frequently results in youth with limited academic success, a continued escalation of behavioral problems, social marginalization, interactions with deviant peers, and a significantly increased likelihood of substance abuse. In addition, the neurobiological changes cataloged above increase the likelihood of developing anxiety disorders (Romer & Walker, p. 350) and substance-related problems (Romer & Walker, p. 446).
Simply put, not only are these youth stuck with maladaptive cognitive scripts, they are these stuck in a seemingly endless cascade of chaos. For these adolescents, school failure, negative peer relations, environmental stressors, mental health disorders, and substance abuse are all likely to co-evolve. An additional factor in this co-evolution is brain development. For an adolescent already suffering the negative impacts from early childhood trauma, the additional impact caused by these environmental problems would likely contribute to his cascade of problems.
A former client, “Andrew,” illustrates this. By the age of three, Andrew’s parents were both heroin dependent and the family lived in a car. It is reasonable to make two assumptions here. First, the environmental stressors caused by addicted parents and homelessness had already negatively impacted Andrew's brain development. Second, with both parents heroin dependent, Andrew likely had a genetic predisposition for addiction.
At age four, Andrew witnessed the death-by-overdose of both parents. With no relatives to provide care, he entered the foster care system. Between four and 15 he had over a dozen different placements. Andrew reported, “I moved around so much that I didn’t even unpack my suitcase.” Not surprisingly, his behavior became increasing problematic. He reported first use of alcohol at age 10 and first use of marijuana shortly thereafter. At 13 he went to detention for the first time. At 15, he ran away from the group home where he was living.
When I met Andrew, he was 16 years old and had just moved into a shelter after being homeless for almost a year. He reported two recent physical assaults and had mental health diagnoses that included PTSD, Conduct Disorder, ADHD and Major Depressive Disorder. He also had diagnoses for Alcohol Dependence, Cannabis Dependence, Opiate Abuse, and Amphetamine Abuse. In addition, Andrew exhibited difficulty remembering details, time frames, and other factual information. Andrew reported using because “it makes me feel normal,” even though he acknowledged amphetamines made him “jittery and paranoid.” With a blank look he continued, “I guess jittery and paranoid is my normal.”
Being Stuck
Working with teens that have co-occurring disorders, I see a lot of clients with a history of trauma. Like Andrew, these adolescents frequently appear to be stuck in an endless cascade of chaos. Here are two additional examples:
• “Carl” is 16 and a convicted felon for multiple car thefts. He suffered physical and emotional abuse from his father starting around age four. At age six his mother died. All three older brothers have drug problems; two of them are currently in jail. Carl has diagnoses of Cocaine Dependence, Cannabis Abuse, Alcohol Abuse and PTSD.
• “Melissa” is 15. She grew up subjected to significant neglect at the hands of her mentally ill mother and was sexually abused by several of her mother’s boyfriends. In addition to diagnoses of Amphetamine Dependence, Alcohol Abuse and Cannabis Abuse, Melissa has a history of disordered eating, suicidal ideation and self-harming behaviors.
Most of my clients don’t have histories as intense as Andrew, Carl or Melissa. however, the majority of them have experienced neglect, parental substance abuse, or other traumatic stress. In my experience, the more severe the history of trauma, the more likely the client will be using stimulants. Stimulants replicate trauma by releasing dopamine and noradrenaline, which are released during the hyper-arousal response. “Brain changes related to hyper-arousal may make some trauma victims more prone to stimulant addiction” (Perry & Szalavitz, p. 190). If this is so, then are these adolescents attempting to recreate the feeling of trauma from their pasts? This likely isn’t their overt intention. However, as Melissa said, “I only feel normal when I’m on meth.” Her brain has changed to make this hyper-arousal her normal state of being.
Melissa’s entire life has contributed to a trauma-focused development of her brain. By using meth, she artificially stimulates the production of those neurotransmitters that she has physically become accustomed to being present. For Melissa and others, perhaps the absence of stress-induced neurotransmitters should be considered a type of withdrawal. Perhaps, these youth are using stimulants to avoid withdrawal caused by a decrease in their accustomed levels of dopamine and noradrenaline caused by the past trauma.
Likewise, perhaps the extreme behavior many of these youth engage in—auto theft, prostitution, drug dealing, risky sex, graffiti, running away, assault, and more—is also a way to increase levels of dopamine and noradrenaline, thereby avoiding withdrawal from stress-related neurotransmitters.
For years I have referred to these clients as “chaos junkies”—a term these youth readily understand and frequently acknowledge as true—but always thought of this as a psychologically based behavioral pattern, a repeating of life strategies that had been modeled in chaotic family environments. Could there be something more happening here? Could these youth actually be physically addicted chaos? More accurately, could these youth be physically dependent upon the chemicals released as a result of the stress caused by their chaotic lifestyles and environments?
This isn’t true for all my clients, but I definitely believe some of them—such as Carl, Melissa and Andrew—are addicted to the cascades of chaos in their lives. If our goal as a substance abuse counselors is to help these adolescents create more adaptive cognitive scripts, then part of my work must to help them resolve their addictions to chaos.
In my experience, teens without a history of significant trauma do not typically identify stimulants as a drug of choice. They may have tried meth, crack or Ecstasy, but only in limited amounts. In fact, it seems to me that stimulant dependence or abuse in adolescents could be considered indicative of trauma. Unfortunately, for these youth, this sign—as well as others—is often missed. Andrew, Melissa, and Carl all came into treatment with long lists of diagnoses such as Conduct Disorder, Major Depressive Disorder, Bipolar Disorder, and Attention Deficient-Hyperactivity Disorder, among others.
While it is possible that those other issues might be present in some cases, without addressing their obvious trauma-laden histories that positive growth seems unlikely. Acknowledging, understanding and addressing the traumatic histories of these youth allows for the possibility of getting unstuck. First, though, it is important to further explore why these youth stay stuck.
Staying Stuck
Thus far, I’ve looked at traumatic experiences as causal pathway for substance abuse in adolescents. While this appears to be the primary causal pathway among adolescents and adult, it is possible for substance abuse to lead to trauma. For Melissa, prostitution helped pay for her expensive drug habit of meth and cocaine. It also led to multiple sexual assaults. For Carl, a severe lack of impulse control and untreated Attention Deficient-Hyperactivity Disorder was at the root of repeated auto thefts, high-speed car chases with the police, and stimulant dependence. It also led to repeated jail sentences. For Andrew, drug dealing supported his substance abuse. It also led to several physical assaults.
These high-risk behaviors clearly re-traumatize the youth. In other cases, such high-risk behavior could be the causation of the initial trauma. Either way, it is easy to see that these youth are stuck. As stated already, Andrew currently lives in a group home. This group home has a drug testing policy and continued use will result in him losing his placement. Yet, he continues to use. Some chemical dependency counselors would say Andrew is in denial, or maybe he’s resistant to treatment, but either way until he “hits his bottom” nobody will be able to help him.
I believe this assessment of Andrew is both simplistic and pessimistic, and so I offer a different analysis: Andrew is not resistant and he is not in denial. In fact, he readily acknowledges the problems in his life. But, he is stuck. His lifelong cascade of problems has impacted his brain’s architecture in ways that have shaped his behavior and determined his cognitive scripts. Andrew knows no responses to his world but acting up, shutting down or using. Furthermore, I believe his brain is not physically capable of making other choices. Helping Andrew become unstuck requires discovering ways to assist him create, practice and then apply more adaptive cognitive scripts.
Writing New Scripts
Evans and Sullivan wrote, “Survivors frequently have excellent artistic abilities, a reflection of their extensive use of right-hemisphere survival strategies” (p. 143). If this is true, then experiential learning—including initiatives, games, art therapy, music therapy, games, and other activities—could be a vital clinical approach for working with trauma survivors. Ross and Bernstein support this conclusion. They wrote, “[G]ames and activities offer youth a workshop for discovering and developing new ways to manage obstacles” (qtd in Rose, p. 24).
Active, experiential learning achieves this goal by not only providing participants the opportunity to try new behaviors, but to also practice them in a safe, supportive environment. In addition, these interactive approaches provide opportunities to increase problem-solving skills, self-efficacy and openness to taking good risks, so that the participants are willing to implement these newly developed, more adaptive scripts.
For adolescents struggling with both substance abuse and traumatic stress, remaining stuck in chaos is a safe, tempting possibility. Melissa stated once, “When I smoke weed, all the bad feelings go away. I don’t want to cut. I don’t want to purge. As long as I’m high, everything seems okay.” As we’ve seen, substance-related disorders and traumatic stress are frequently an intricate, co-evolving, cascading series of obstacles. Helping youth get unstuck from this loop requires challenging these adolescents to risk developing new cognitive scripts.
Works Cited
Lawson, G. & Lawson, A. (1992). Adolescent Substance Abuse. Gaithersburg, ME: Aspen Publishing.
Perry, B. & Szalavitz, M. (2006). Boy Who Was Raised as a Dog, The. New York: Basic Books.
Romer, D. & Walker, E. (2007). Adolescent Psychopathology and the Developing Brain. New York: Oxford University Press.
Rose, S. (1998). Group Therapy with Troubled Youth. Thousand Oaks, CA: Sage Publications.
Siegel, D. (1999). Developing Mind, The. New York: Guilford Press.
Sunday, December 21, 2008
Saturday, December 6, 2008
Breaking the Cycle of Stuckness
As I’ve written before, my clients often have highly maladaptive cognitive scripts, routinely utilizing one of three cognitive scripts. They act up, shut down, or use mood-altering substances. While these responses might not seem especially effective to someone with more adaptive cognitive scripts, they are predictable and therefore safe. Rose wrote that most youth with multiple life problems—as is the case with nearly all my clients— “seem to have dedicated and rigid strategies for dealing with problems and are disinclined to look at other possibilities" (p. 177).
Looking at other possibilities requires a willingness to try something new, to step outside your Comfort Zone, to take risks. For youth who have had lives filled with unpredictability, even the most painful known option can feel less risky than any unknown one. “Steve,” a former client, summed this up when he said, “What I like the most about drugs is that I know what to expect. I smoke. I get high. No surprises.” For youth like Steve, there is an inherent reinforcement in a life of “no surprises.” Unlike many of other aspects of his life, he knows what to expect when he uses. And, that predictability is appealing.
However, a life of "no surprises" can lead to a cycle of stuckness. A basic tenet of brain development is that what fires together wires together. Through repetition of the same behavior, neuronal connections are created and then reinforced. Just like tying shoes becomes easier over time as a result of neurons wiring together, cognitive scripts also become hard wired in the brain. In other words, the maladaptive scripts of acting up, shutting down and using become part of the individual’s brain structure.
This means that Steve, like many youth, is cognitively stuck. His brain is hard wired to respond to life in maladaptive ways. Facilitating for change requires helping these youth break this cycle of stuckness. Experiential learning provides an effective methodology for doing this, because it “challenge[s] participants to update, refine, and alter mental programs when they emerge” (Luckner & Nadler, p. 36).
This updating, refining and altering can occur thanks to neuroplasticity, “the brain’s ability to physically change in response to stimuli and activity” (Romer & Walker, p. 484). It is “the ability of neurons to change the way they behave and relate to one another as the brain adapts to the environment through time” (Cozolino, p. 75). Neuroplasticity allows us to create new cognitive scripts.
Paula Tallal of Rutgers University stated, “You create your brain from the input you get” (qtd. in Begley, p. 105). It seems to me that it logically follows that that if you change the input, you would change the brain. Therapy or counseling provides an effective methodology for changing the input in a controlled and intentional manner. Cozolino supports this conclusion by writing, “[T]he therapeutic context may enhance the brain’s ability to rewire through concurrent emotional and cognitive processing. Successful therapeutic techniques may be successful because of their very ability to change brain chemistry in a manner that enhances neural plasticity” (p. 300).
“An enriched environment is one that is characterized by a level of stimulation and complexity that enhances learning and growth… [E]nriched environments can include the kinds of challenging educational and experiential opportunities that encourage us to learn new skills and expand our knowledge” (Cozolino, p. 22-23). A study conducted by the University of British Columbia helps to support the conclusion by Priest and Gass.
In this study, mice that were provided exercise wheels developed neurons that were “dramatically different” from sedentary mice. These exercise wheels provided the mice a more enriched environment, and in response their neurons had more dendrites, which are responsible for receiving signals from other neurons. This means the thinking patterns of these mice was more complex, more able to solve problems, and more able to engage in lasting learning (Begley, p. 69).
Cozolino suggests that any therapeutic approach will provide the enriched environment he describes. It seems to me, though, that experiential learning is particularly well suited for enhancing neuroplasticity. Experiential learning takes the "talk therapy" of other methodologies and puts that learning into action. Experiential learning tests what other methodologies often leave as "inert ideas" (Whitehead, qtd. in Zull, p. 206). According to Zull, "Action forces our mental constructs out of our brains and into the reality of the physical world" ( p. 206). Without that active testing, these new ideas are unlikely to ever be integrated into new behaviors. Active testing, then, is what allows us to rehearse new cognitive scripts.
Neuroplasticity in Action
Priest and Gass outlined six characteristics of experiential learning: the participant is provided a direct and purposeful experience, the participant is appropriately challenged, the participant is presented with opportunities for synthesis and reflection, the experience provides for natural consequences, the experience emphasizes participant-driven change, and the experience has both present and future relevance (p. 146-147).
All six of these characteristics are important to assure the most beneficial learning experience possible. However, it seems to me that for facilitators of experiential learning in clinical settings, focusing on participant-driven change is especially relevant. “Challenges that force us to expand our awareness, learn new information, or push beyond assumed limits can all change our brains” (Cozolino, p. 291).
Experiential learning regularly utilizes activities intended to push participants beyond their assumed limits, or to step outside their Comfort Zone. This provides participants the opportunity to test their assumptions and reject those they discover to be faulty. Because this testing is participant-driven, it is more developmentally appropriate for teens than more prescriptive counseling methodologies.
Zull wrote, “When we test our ideas, we are changing the abstract into the concrete. We convert our mental ideas into physical events” (p. 208). Converting mental ideas into physical events is exactly why experiential learning is an especially effective methodology for ending the cycle of stuckness. I would add, though, that once a mental construct has been forced into the physical world and discovered to be faulty, it is likely to be abandoned.
Rehearsing Change
As we have seen, experiential learning provides an effective method for testing and rejecting. Experiential learning provides two additional methods for helping end the cycle of stuckness. First, this methodology provides participants an opportunity to practice alternative behavioral choices. When used effectively and chosen for their relevance to the clinical work at hand, experiential learning allows youth like Steve to alter their cognitive scripts by putting new learning into practice in ways that will be memorable and concrete. In other words, experiential learning provides an opportunity to rehearse new scripts.
Second, experiential learning provides participants the opportunity to engage in healthy risk taking. For youth like Steve who prefer a life of no surprises, acting up, shutting down and using are so germane to their maladaptive scripts that these behaviors have become normalized. Thus, they are no longer perceived as risky.
In the Stages of Change model, these youth are pre-contemplative. Part of the appeal of pre-contemplation is that it feels safe (Prochaska, Norcross & DiClemente, p. 74). These youth often exhibit significant cognitive dissonance, perceiving high-risk situations as risk-free. This is, perhaps, the ultimate maladaptive script and part of their stuckness is their inability to see it. Helping them become unstuck requires helping them to reframe this dissonance, so that they move through the Stages of Change. Helping them become unstuck requires that they come to see risky behavior as risky.
Priest and Gass have cataloged significant affective gains from participation in experiential learning. These include new self-confidence, enhanced willingness to take good risks, improved self-concept, increased logical thinking, and greater reflective thinking (p. 19). These affective gains would be useful for anyone engaged in the change process, but they are particularly useful for someone stuck in pre-contemplation.
As illustrated, the use of experiential learning in clinical settings seems an obvious and valuable choice, leading to a “more enriched, complex, and potentially resilient brain” (Cozolino, p. 298). Experiential learning provides an excellent methodology for assuring this treatment outcome, by providing an “enriched environment to enhance brain development” (Cozolino, p. 291). These developments result in increased confidence and optimism regarding the ability to change. This is vital in helping assure that youth like Steve will actually utilize their new developed, more adaptive cognitive scripts.
“The concept of neuroplasticity suggests that the brain is highly malleable and is subject to continual change as a result of experience, so that new connections between neurons may be formed or even brand-new neurons generated” (The Dalai Lama, qtd. in Begley, p. 24). By providing rich opportunities to test assumptions, practice new behaviors, and engage in healthy risk taking, experiential learning inevitably enhances neuroplasticity, thereby leading to lasting changes in cognitive scripts. It is through this learning, rehearsing, and ultimate using of new, more adaptive cognitive scripts that youth like Steve can break their cycle of stuckness.
Works Cited
Begley, S. (2007). Train Your Mind, Change Your Brain. New York: Ballantine Books.
Cozolino, L. (2002). Neuroscience of Psychotherapy, The. New York: W. W. Norton & Co.
Luckner, J. & Nadler, R. (1992). Processing the Experience. Dubuque, IA: Kendall/Hunt Publishing.
Priest, S., & Gross, M. (2005). Effective Leadership in Adventure Programming. Champaign, IL: Human Kinestics.
Prochaska, J., Norcross, J., & DiClemente, C. (1994). Changing for Good. New York: Harper Collins.
Romer, D. & Walker, E. (2007). Adolescent Psychopathology and the Developing Brain. New York: Oxford University Press.
Rose, S. (1998). Group Therapy with Troubled Youth. Thousand Oaks, CA: Sage Publications.
Zull, J. (2002). Art of Changing the Brain, The. Sterling, VA: Stylus Publishing.
Looking at other possibilities requires a willingness to try something new, to step outside your Comfort Zone, to take risks. For youth who have had lives filled with unpredictability, even the most painful known option can feel less risky than any unknown one. “Steve,” a former client, summed this up when he said, “What I like the most about drugs is that I know what to expect. I smoke. I get high. No surprises.” For youth like Steve, there is an inherent reinforcement in a life of “no surprises.” Unlike many of other aspects of his life, he knows what to expect when he uses. And, that predictability is appealing.
However, a life of "no surprises" can lead to a cycle of stuckness. A basic tenet of brain development is that what fires together wires together. Through repetition of the same behavior, neuronal connections are created and then reinforced. Just like tying shoes becomes easier over time as a result of neurons wiring together, cognitive scripts also become hard wired in the brain. In other words, the maladaptive scripts of acting up, shutting down and using become part of the individual’s brain structure.
This means that Steve, like many youth, is cognitively stuck. His brain is hard wired to respond to life in maladaptive ways. Facilitating for change requires helping these youth break this cycle of stuckness. Experiential learning provides an effective methodology for doing this, because it “challenge[s] participants to update, refine, and alter mental programs when they emerge” (Luckner & Nadler, p. 36).
This updating, refining and altering can occur thanks to neuroplasticity, “the brain’s ability to physically change in response to stimuli and activity” (Romer & Walker, p. 484). It is “the ability of neurons to change the way they behave and relate to one another as the brain adapts to the environment through time” (Cozolino, p. 75). Neuroplasticity allows us to create new cognitive scripts.
Paula Tallal of Rutgers University stated, “You create your brain from the input you get” (qtd. in Begley, p. 105). It seems to me that it logically follows that that if you change the input, you would change the brain. Therapy or counseling provides an effective methodology for changing the input in a controlled and intentional manner. Cozolino supports this conclusion by writing, “[T]he therapeutic context may enhance the brain’s ability to rewire through concurrent emotional and cognitive processing. Successful therapeutic techniques may be successful because of their very ability to change brain chemistry in a manner that enhances neural plasticity” (p. 300).
“An enriched environment is one that is characterized by a level of stimulation and complexity that enhances learning and growth… [E]nriched environments can include the kinds of challenging educational and experiential opportunities that encourage us to learn new skills and expand our knowledge” (Cozolino, p. 22-23). A study conducted by the University of British Columbia helps to support the conclusion by Priest and Gass.
In this study, mice that were provided exercise wheels developed neurons that were “dramatically different” from sedentary mice. These exercise wheels provided the mice a more enriched environment, and in response their neurons had more dendrites, which are responsible for receiving signals from other neurons. This means the thinking patterns of these mice was more complex, more able to solve problems, and more able to engage in lasting learning (Begley, p. 69).
Cozolino suggests that any therapeutic approach will provide the enriched environment he describes. It seems to me, though, that experiential learning is particularly well suited for enhancing neuroplasticity. Experiential learning takes the "talk therapy" of other methodologies and puts that learning into action. Experiential learning tests what other methodologies often leave as "inert ideas" (Whitehead, qtd. in Zull, p. 206). According to Zull, "Action forces our mental constructs out of our brains and into the reality of the physical world" ( p. 206). Without that active testing, these new ideas are unlikely to ever be integrated into new behaviors. Active testing, then, is what allows us to rehearse new cognitive scripts.
Neuroplasticity in Action
Priest and Gass outlined six characteristics of experiential learning: the participant is provided a direct and purposeful experience, the participant is appropriately challenged, the participant is presented with opportunities for synthesis and reflection, the experience provides for natural consequences, the experience emphasizes participant-driven change, and the experience has both present and future relevance (p. 146-147).
All six of these characteristics are important to assure the most beneficial learning experience possible. However, it seems to me that for facilitators of experiential learning in clinical settings, focusing on participant-driven change is especially relevant. “Challenges that force us to expand our awareness, learn new information, or push beyond assumed limits can all change our brains” (Cozolino, p. 291).
Experiential learning regularly utilizes activities intended to push participants beyond their assumed limits, or to step outside their Comfort Zone. This provides participants the opportunity to test their assumptions and reject those they discover to be faulty. Because this testing is participant-driven, it is more developmentally appropriate for teens than more prescriptive counseling methodologies.
Zull wrote, “When we test our ideas, we are changing the abstract into the concrete. We convert our mental ideas into physical events” (p. 208). Converting mental ideas into physical events is exactly why experiential learning is an especially effective methodology for ending the cycle of stuckness. I would add, though, that once a mental construct has been forced into the physical world and discovered to be faulty, it is likely to be abandoned.
Rehearsing Change
As we have seen, experiential learning provides an effective method for testing and rejecting. Experiential learning provides two additional methods for helping end the cycle of stuckness. First, this methodology provides participants an opportunity to practice alternative behavioral choices. When used effectively and chosen for their relevance to the clinical work at hand, experiential learning allows youth like Steve to alter their cognitive scripts by putting new learning into practice in ways that will be memorable and concrete. In other words, experiential learning provides an opportunity to rehearse new scripts.
Second, experiential learning provides participants the opportunity to engage in healthy risk taking. For youth like Steve who prefer a life of no surprises, acting up, shutting down and using are so germane to their maladaptive scripts that these behaviors have become normalized. Thus, they are no longer perceived as risky.
In the Stages of Change model, these youth are pre-contemplative. Part of the appeal of pre-contemplation is that it feels safe (Prochaska, Norcross & DiClemente, p. 74). These youth often exhibit significant cognitive dissonance, perceiving high-risk situations as risk-free. This is, perhaps, the ultimate maladaptive script and part of their stuckness is their inability to see it. Helping them become unstuck requires helping them to reframe this dissonance, so that they move through the Stages of Change. Helping them become unstuck requires that they come to see risky behavior as risky.
Priest and Gass have cataloged significant affective gains from participation in experiential learning. These include new self-confidence, enhanced willingness to take good risks, improved self-concept, increased logical thinking, and greater reflective thinking (p. 19). These affective gains would be useful for anyone engaged in the change process, but they are particularly useful for someone stuck in pre-contemplation.
As illustrated, the use of experiential learning in clinical settings seems an obvious and valuable choice, leading to a “more enriched, complex, and potentially resilient brain” (Cozolino, p. 298). Experiential learning provides an excellent methodology for assuring this treatment outcome, by providing an “enriched environment to enhance brain development” (Cozolino, p. 291). These developments result in increased confidence and optimism regarding the ability to change. This is vital in helping assure that youth like Steve will actually utilize their new developed, more adaptive cognitive scripts.
“The concept of neuroplasticity suggests that the brain is highly malleable and is subject to continual change as a result of experience, so that new connections between neurons may be formed or even brand-new neurons generated” (The Dalai Lama, qtd. in Begley, p. 24). By providing rich opportunities to test assumptions, practice new behaviors, and engage in healthy risk taking, experiential learning inevitably enhances neuroplasticity, thereby leading to lasting changes in cognitive scripts. It is through this learning, rehearsing, and ultimate using of new, more adaptive cognitive scripts that youth like Steve can break their cycle of stuckness.
Works Cited
Begley, S. (2007). Train Your Mind, Change Your Brain. New York: Ballantine Books.
Cozolino, L. (2002). Neuroscience of Psychotherapy, The. New York: W. W. Norton & Co.
Luckner, J. & Nadler, R. (1992). Processing the Experience. Dubuque, IA: Kendall/Hunt Publishing.
Priest, S., & Gross, M. (2005). Effective Leadership in Adventure Programming. Champaign, IL: Human Kinestics.
Prochaska, J., Norcross, J., & DiClemente, C. (1994). Changing for Good. New York: Harper Collins.
Romer, D. & Walker, E. (2007). Adolescent Psychopathology and the Developing Brain. New York: Oxford University Press.
Rose, S. (1998). Group Therapy with Troubled Youth. Thousand Oaks, CA: Sage Publications.
Zull, J. (2002). Art of Changing the Brain, The. Sterling, VA: Stylus Publishing.
Tuesday, December 2, 2008
Readiness to Change
As I’ve previously written, I believe that making change is about resolving ambivalence. Miller and Rollnick wrote that when facilitating change in others, “It is useful in understanding a person’s ambivalence to know his or her perceptions of both importance and confidence” (p. 53). This balance between importance and confidence can be thought of as an individual’s readiness for change (Miller & Rollnick, p. 54).
Within the chemical dependency field, an individual’s readiness to change is given much important. Per standards set by the American Society of Addiction Medicine (ASAM), readiness to change has been identified as one of six areas, or dimensions, to be evaluated during an initial substance abuse assessment and to be re-evaluated during monthly updates.
As a drug/alcohol counselor, I clearly think a lot about readiness to change in others. Indeed, much of what I do as a clinician is really about helping clients to increase their readiness to change. However, it seems to me that this is presented as a vague concept within the ASAM assessment criteria. Basically, the more resistant an individual appears, the lower his readiness to change. However, if resistance truly is “an unhelpful idea that has handicapped therapists” (Selekman, p. 32), it seems unproductive to use it as a means of assessment. Worse, this pessimist mindset seems likely to keep the client stuck.
After all, if a client is resistant and therefore completely unwilling to engage in treatment, even the most skilled clinician would be left with no options. These clients sit in treatment for a while, refusing to engage, then get discharged for being non-compliant, not amiable to treatment, or unwilling to participate in their own recovery. Shame on them! Clients may not enter treatment resistant to the process, but they do sometimes leave that way. Or, as Seligman wrote, “Pessimistic prophecies are self-fulfilling” (p. 6).
Recently, I began working with “Michael.” Michael had been working with another clinician for about two months when he was referred to me. The clinician stated, “He doesn’t want to do any work and is completely unwilling to engage in treatment. I think he needs mental health services.” Michael’s attendance at group and individual sessions had been poor thus far, and the referring clinician stated that he was “adamant” about continuing to use marijuana and alcohol. The referring clinician also used that word resistant many, many times during our one conversation about this client.
The Process of Change
I believe a useful way to evaluate readiness to change is by assessing the individual’s Stage of Change. According to Stages of Change theory, lasting change is a process, with the individual moving through six distinct stages. These are pre-contemplation, contemplation, preparation, action, maintenance, and termination. Each stage “entails a series of tasks that need to be completed before progress to the next stage” (Prochaska, Norcross & DiClemente, p. 39). Sometimes, an individual returns to a prior stage in order to do more work. Within this model, that’s not a failure, just part of the process. In fact, I believe that recovery is an experiential process, and that relapse can be the most important part of that process.
Traditionally, most substance abuse programs assumed all clients entering treatment were in the action stage. To me, this is just absurd, especially when you consider that most clients—like Michael—are mandated in the first place. Perhaps resistance is really about this misfit of stages. If an individual is pre-contemplative and being treated as if he is ready to take action, wouldn’t he appear non-compliant, not amiable to treatment, and unwilling to engage? That certainly describes Michael. When I first met him, my perspective was a bit different than the referring clinician’s.
Michael was—and remains—a challenging client who tests boundaries, is likely to debate minor details, and always does the minimum required. However, he wasn’t resistant. Rather, he was stuck in pre-contemplation. Like anyone in pre-contemplation, Michael didn’t believe he had a problem. Since he didn’t have a problem, why should he change anything? And, the more people pushed him to take action, the less likely it would happen.
Miller and Rollnick wrote, “ When the idea of change or treatment is forced on an unwilling recipient it is not uncommon for the individual to engage in the problem behavior to a greater extent in an attempt to assert his or her freedom” (p. 337). According to the referring clinician, Michael’s using had increased since starting treatment. In fact, the referring clinician offered this information as proof of Michael’s resistance.
If Michael was actually stuck in pre-contemplation, my efforts shouldn't be to get him to take action. My efforts should be to help him get unstuck. Prochaska, Norcross and DiClemente have identified specific tasks for each Stage of Change. I have found these stage-specific tasks to be useful when working with clients. I've also found that the Stages of Change model and motivational interviewing have much in common. In fact, Miller and Rollnick wrote, “[M]otivational interviewing can be used to assist individuals to accomplish the various tasks required to transition form the pre-contemplation stage through the maintenance stage” (p. 202). Employing basic motivational interviewing principles when doing Stages of Change work seems a natural choice.
Miller and Rollnick identified four general principles for motivational interviewing. These are express empathy, develop discrepancy, roll with resistance, and support self-efficacy (p. 36). Especially when combined with stage-specific tasks, these principles are highly effective in helping clients move through the Stages of Change (Miller & Rollnick, p. 203). And, when the clients are successful, they are also developing the confidence to continue their change process.
The Confidence to Change
Miller and Rollnick wrote, “Readiness [to change] implies at least some degree of both importance and confidence. A person who does not see change as important is unlikely to be ready to change. Similarly, people who see change as impossible are unlikely to say they are ready to do it” (p. 54). Initially, Michael didn’t see change as important, but he also had doubts about his ability to make meaningful change.
I proposed two goals for Michael. First, address the tasks of pre-contemplation so he could start making some movement on the Stages of Change. Second, increase his sense of self-efficacy and thereby improve his optimism. When I presented this plan to Michael, his only response was, “Whatever. As long as I don’t get my probation revoked.” That lead to a third goal for Michael: do what is necessary to stay out of detention, which meant attending weekly individual sessions with me and having clear UAs.
Michael was reluctant to stop his use, but agreed to this plan because, in his words, “I’ll go to detention if I don’t.” I’ve only been working with this client for a short time, but clear progress has already occurred. Michael has been present at all his scheduled appointments. He's also making reasonable progress on pre-contemplation tasks. In our last appointment, he stated, “I don’t think I’ve got a problem using, but everyone else does, and that’s a problem, I guess. ” This may not sound like progress to some. I’m sure it wouldn’t to that referring clinician. To me, though, it clearly represents signs of becoming unstuck.
Instead of the pessimism of resistance, a new perspective is offered by the combination of the Stages of Change model and motivational interviewing: Even the most reluctant clients are simply working on the tasks of their current stage. Thought of this way, the job of a professional helper is reframed from the thankless task of overcoming resistance to that of assisting clients to increase their readiness to change.
Works Cited
Miller, W., & Rollnick, S. (2002). Motivational Interviewing. New York: Guilford Press.
Prochaska, J., Norcross, J., & DiClemente, C. (1994). Changing for Good. New York: Harper Collins.
Selekman, M. (2005). Pathways to Change. New York: Guilford Press.
Seligman, M. (1990). Learned Optimism. New York: Random House.
Within the chemical dependency field, an individual’s readiness to change is given much important. Per standards set by the American Society of Addiction Medicine (ASAM), readiness to change has been identified as one of six areas, or dimensions, to be evaluated during an initial substance abuse assessment and to be re-evaluated during monthly updates.
As a drug/alcohol counselor, I clearly think a lot about readiness to change in others. Indeed, much of what I do as a clinician is really about helping clients to increase their readiness to change. However, it seems to me that this is presented as a vague concept within the ASAM assessment criteria. Basically, the more resistant an individual appears, the lower his readiness to change. However, if resistance truly is “an unhelpful idea that has handicapped therapists” (Selekman, p. 32), it seems unproductive to use it as a means of assessment. Worse, this pessimist mindset seems likely to keep the client stuck.
After all, if a client is resistant and therefore completely unwilling to engage in treatment, even the most skilled clinician would be left with no options. These clients sit in treatment for a while, refusing to engage, then get discharged for being non-compliant, not amiable to treatment, or unwilling to participate in their own recovery. Shame on them! Clients may not enter treatment resistant to the process, but they do sometimes leave that way. Or, as Seligman wrote, “Pessimistic prophecies are self-fulfilling” (p. 6).
Recently, I began working with “Michael.” Michael had been working with another clinician for about two months when he was referred to me. The clinician stated, “He doesn’t want to do any work and is completely unwilling to engage in treatment. I think he needs mental health services.” Michael’s attendance at group and individual sessions had been poor thus far, and the referring clinician stated that he was “adamant” about continuing to use marijuana and alcohol. The referring clinician also used that word resistant many, many times during our one conversation about this client.
The Process of Change
I believe a useful way to evaluate readiness to change is by assessing the individual’s Stage of Change. According to Stages of Change theory, lasting change is a process, with the individual moving through six distinct stages. These are pre-contemplation, contemplation, preparation, action, maintenance, and termination. Each stage “entails a series of tasks that need to be completed before progress to the next stage” (Prochaska, Norcross & DiClemente, p. 39). Sometimes, an individual returns to a prior stage in order to do more work. Within this model, that’s not a failure, just part of the process. In fact, I believe that recovery is an experiential process, and that relapse can be the most important part of that process.
Traditionally, most substance abuse programs assumed all clients entering treatment were in the action stage. To me, this is just absurd, especially when you consider that most clients—like Michael—are mandated in the first place. Perhaps resistance is really about this misfit of stages. If an individual is pre-contemplative and being treated as if he is ready to take action, wouldn’t he appear non-compliant, not amiable to treatment, and unwilling to engage? That certainly describes Michael. When I first met him, my perspective was a bit different than the referring clinician’s.
Michael was—and remains—a challenging client who tests boundaries, is likely to debate minor details, and always does the minimum required. However, he wasn’t resistant. Rather, he was stuck in pre-contemplation. Like anyone in pre-contemplation, Michael didn’t believe he had a problem. Since he didn’t have a problem, why should he change anything? And, the more people pushed him to take action, the less likely it would happen.
Miller and Rollnick wrote, “ When the idea of change or treatment is forced on an unwilling recipient it is not uncommon for the individual to engage in the problem behavior to a greater extent in an attempt to assert his or her freedom” (p. 337). According to the referring clinician, Michael’s using had increased since starting treatment. In fact, the referring clinician offered this information as proof of Michael’s resistance.
If Michael was actually stuck in pre-contemplation, my efforts shouldn't be to get him to take action. My efforts should be to help him get unstuck. Prochaska, Norcross and DiClemente have identified specific tasks for each Stage of Change. I have found these stage-specific tasks to be useful when working with clients. I've also found that the Stages of Change model and motivational interviewing have much in common. In fact, Miller and Rollnick wrote, “[M]otivational interviewing can be used to assist individuals to accomplish the various tasks required to transition form the pre-contemplation stage through the maintenance stage” (p. 202). Employing basic motivational interviewing principles when doing Stages of Change work seems a natural choice.
Miller and Rollnick identified four general principles for motivational interviewing. These are express empathy, develop discrepancy, roll with resistance, and support self-efficacy (p. 36). Especially when combined with stage-specific tasks, these principles are highly effective in helping clients move through the Stages of Change (Miller & Rollnick, p. 203). And, when the clients are successful, they are also developing the confidence to continue their change process.
The Confidence to Change
Miller and Rollnick wrote, “Readiness [to change] implies at least some degree of both importance and confidence. A person who does not see change as important is unlikely to be ready to change. Similarly, people who see change as impossible are unlikely to say they are ready to do it” (p. 54). Initially, Michael didn’t see change as important, but he also had doubts about his ability to make meaningful change.
I proposed two goals for Michael. First, address the tasks of pre-contemplation so he could start making some movement on the Stages of Change. Second, increase his sense of self-efficacy and thereby improve his optimism. When I presented this plan to Michael, his only response was, “Whatever. As long as I don’t get my probation revoked.” That lead to a third goal for Michael: do what is necessary to stay out of detention, which meant attending weekly individual sessions with me and having clear UAs.
Michael was reluctant to stop his use, but agreed to this plan because, in his words, “I’ll go to detention if I don’t.” I’ve only been working with this client for a short time, but clear progress has already occurred. Michael has been present at all his scheduled appointments. He's also making reasonable progress on pre-contemplation tasks. In our last appointment, he stated, “I don’t think I’ve got a problem using, but everyone else does, and that’s a problem, I guess. ” This may not sound like progress to some. I’m sure it wouldn’t to that referring clinician. To me, though, it clearly represents signs of becoming unstuck.
Instead of the pessimism of resistance, a new perspective is offered by the combination of the Stages of Change model and motivational interviewing: Even the most reluctant clients are simply working on the tasks of their current stage. Thought of this way, the job of a professional helper is reframed from the thankless task of overcoming resistance to that of assisting clients to increase their readiness to change.
Works Cited
Miller, W., & Rollnick, S. (2002). Motivational Interviewing. New York: Guilford Press.
Prochaska, J., Norcross, J., & DiClemente, C. (1994). Changing for Good. New York: Harper Collins.
Selekman, M. (2005). Pathways to Change. New York: Guilford Press.
Seligman, M. (1990). Learned Optimism. New York: Random House.
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